Current Issue Search Articles Instructions for authors
 

 HOME | Login   

 

 Small font sizeDefault font sizeIncrease font size Print this article Email this article Bookmark this page
 Users online: 1186


  In this article
    Abstract
    Introduction
    Materials and Me...
    Results
    Discussion
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed6423    
    Printed306    
    Emailed0    
    PDF Downloaded125    
    Comments [Add]    
    Cited by others 2    

Recommend this journal

 
 
Year : 2009  |  Volume : 3  |  Issue : 3  |  Page : 53-56    Table of Contents


 
ORIGINAL ARTICLE

The treatment of established non-union of the proximal humerus using the Polarus locking intramedullary nail

1 Department of Orthopaedics, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
2 Raigmore Hospital, Inverness, Scotland, United Kingdom

Correspondence Address:
Steven W Hamilton
Aberdeen Royal Infirmary, Foresterhill, Aberdeen, AB25 2ZN
United Kingdom
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-6042.59970

Rights and Permissions

 

 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Article in PDF (523 KB)
Reader Comments
Access Statistics
Citation Manager
Add to My List *
* Registration required (free)

Date of Web Publication13-Feb-2010

   Abstract 

Introduction: Non-union following fracture of the proximal humerus is not uncommon, particularly in the elderly. This can be associated with significant morbidity due to pain, instability and functional impairment. The Polarus device (Acumed) is a locked, antegrade intramedullary nail designed to stabilize displaced 2-, 3- and 4-part fractures of the proximal humerus. We report our experience with the Polarus nail for the treatment of established non-union of the proximal humerus.
Materials and Methods: A total of 7 Polarus nails were inserted for the treatment of non-union of the proximal humerus between June 2000 and July 2007. Each fracture site was opened, debrided, stabilized with a Polarus nail and then grafted with autologous cancellous iliac crest bone. The time between injury and surgery ranged from 6 to 102 months. One patient had undergone previous fixation of her fracture using Rush intramedullary rods. All patients were females, and mean age at surgery was 63.6 years (range, 49-78 years). A retrospective review of notes and radiographs was carried out. Patients were reviewed at varying intervals postoperatively (range, 13-68 months) and assessed using the Constant shoulder-scoring system.
Results: All un-united fractures progressed to union. There were no wound complications and no postoperative nerve palsies. Functional outcome was good, even in those cases with a long interval between injury and surgery. The mean Constant score was 63 (range, 54-81). Migration of a single proximal locking screw was seen in 2 patients, and these screws required removal at 5 and 12 months, respectively, postoperatively.
Conclusion: In our experience, a locked proximal humeral nail used in conjunction with autologous bone grafting is an excellent device for the treatment of proximal humerus non-unions.


Keywords: Non-union, proximal humerus, locking nail


How to cite this article:
Hamilton SW, Baird KS. The treatment of established non-union of the proximal humerus using the Polarus locking intramedullary nail. Int J Shoulder Surg 2009;3:53-6

How to cite this URL:
Hamilton SW, Baird KS. The treatment of established non-union of the proximal humerus using the Polarus locking intramedullary nail. Int J Shoulder Surg [serial online] 2009 [cited 2019 Aug 26];3:53-6. Available from: http://www.internationalshoulderjournal.org/text.asp?2009/3/3/53/59970



   Introduction Top


Fractures of the proximal humerus account for approximately 5% of all fractures. [1],[2] Their incidence increases rapidly beyond the age of 50 years, and they are twice as common in women than in men. [1],[3],[4] Most heal uneventfully; however, non-union is not uncommon, particularly in the elderly. The incidence of non-union in this group of patients can be as high as 23%. [5] Risk factors for non-union include multiple medical comorbidities, smoking, fracture comminution, alcohol abuse and loss of fixation in osteoporotic bone. [6],[7] Non-union of the proximal humerus results in significant morbidity due to pain, instability and functional impairment. [7],[8] Several operative techniques have been used to treat proximal humerus non-unions with varying success. [6],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17] Treatment of non-union of the proximal humerus continues to be an orthopedic challenge.

The Polarus device (Acumed) is a locked, antegrade intramedullary nail designed to stabilize displaced 2-, 3- and 4-part fractures of the proximal humerus. [18],[19],[20],[21],[22],[23] We report our own experience with the Polarus nail in the treatment of established non-union of the Proximal humerus.


   Materials and Methods Top


Seven patients underwent insertion of a Polarus nail for non-union of the proximal humerus between June 2000 and July 2007 at Raigmore Hospital, Inverness, Scotland, U.K. The second author exclusively treated all 7 patients. Each non-union was exposed via a deltopectoral approach. Fibrous tissue was excised and the bone ends were debrided. In each patient, the proximal fragment was found to retain good soft tissue attachments, with bleeding observed from bone ends. The humeral head was therefore considered viable. A Polarus nail was inserted, locked proximally with up to 4 screws and then distally with 2 screws. The bony defect was then packed with autologous cancellous bone graft harvested from the ipsilateral iliac crest. A structural cortico-cancellous graft or bone peg was not used in any of the cases. One patient had undergone 2 previous operations for persistent non-union. All patients were female with a mean age of 63.6 years (range, 49- 78 years). Established non-union was defined as no clinical or radiological evidence of bony union at 6 months or more after fracture. The time between injury and surgery ranged from 6 to 102 months. In each case, the initial injury was a displaced, 2-part surgical neck of humerus fracture. A retrospective review of notes and radiographs was carried out. Functional assessment of each patient was performed using the Constant shoulder score. Follow-up interval ranged from 13 to 68 months. The clinical data is summarized in [Table 1].


   Results Top


All un-united fractures progressed to union, and a typical example is shown in [Figure 1]. Functional outcome was good even in those patients with a long interval between injury and surgery. The average Constant shoulder score was 63 (range, 54-81). There were no wound complications, no postoperative neurovascular problems and no significant donor site morbidities. Migration of a single proximal screw was observed in 2 patients, which resulted in a localized prominence with mild discomfort in the lateral deltoid area. These symptoms resolved following removal of the screws, under local anesthesia, at 5 and 12 months, postoperatively. One patient had bilateral proximal humerus non-unions that had resulted from non-simultaneous injuries. One was treated by cemented hemiarthroplasty and the other by a Polarus nail with autologous bone grafting. The side with the hemiarthroplasty did not function as well when compared to the nailed side.


   Discussion Top


Non-union of the proximal humerus is a debilitating problem which can be difficult to treat. Various operative treatments with varying rates of success have been described.

Complications following Rush rods with autologous bone grafting include persistent non-union and symptomatic metalwork migration. Scheck [6] reported good results in 5 patients treated with this method. However, Nayak et al. [14] reported poor results in a similar group of 10 patients. Non-union persisted in 2 patients, osteonecrosis of the humeral head developed in 2 patients, while 8 patients required removal of the Rush rods for mechanical impingement.

Hemiarthroplasty provides good pain relief, but function often remains limited despite rotator cuff reconstruction. [8],[11],[14]

Plate fixation with autologous bone grafting has been shown to give better results when compared with Rush rod fixation or hemiarthroplasty. [9],[11],[12],[15] However, soft tissue stripping during plate fixation may increase the risk of osteonecrosis of the humeral head. [7] Sturzenegger et al. [24] reported osteonecrosis in 34% of patients treated with t-plate fixation, although this may have been due to the severity of the fracture. Symptomatic metalwork impingement and soft tissue adhesion to the plate are also recognized complications of this method. However, Walch et al. [17] reported a low complication rate and 96% union with plate fixation when combined with intramedullary bone peg insertion and cancellous bone grafting.

The treatment of surgical neck non-unions with a locked intramedullary nail has previously been described. [13] The locking nail used was designed and manufactured at the center where the study took place. Fourteen out of 15 patients united, but there was a high complication rate: 2 patients had iatrogenic fractures, 2 had locking screws misplaced, 2 screws became loose and 1 suffered a postoperative brachial plexus injury.

All 7 un-united fractures in our study progressed to union. As follow-up was at varying intervals, no conclusions have been drawn regarding time to union. Apart from migration of a single proximal locking screw in 2 patients, there were no complications. In our experience, a locked proximal humeral nail in combination with autologous cancellous bone grafting is a safe and reliable technique for the treatment of non-union of the proximal humerus. We believe that the success of this technique is due to several reasons: 1) There is minimal soft tissue stripping of the proximal fragment during insertion, thereby avoiding further vascular compromise of the humeral head; 2) the fracture fixation is load-sharing, the biomechanics of which help stimulate bone formation; [16] 3) proximal locking by up to 4 divergent cancellous screws provides multiplanar stability, allowing early mobilization of the shoulder. When compared with other nails, the Polarus device has been shown to give a more stable and rigid construct between bone and nail. [25] Proximal humerus non-unions are more often a consequence of instability rather than a problem with vascularity. Therefore, in some cases stabilization with a locked proximal humeral nail without bone grafting could be a further treatment option.

 
   References Top

1.Reid JS. Fractures of the proximal humerus. Curr Op in Orthop 2003;14:269-80.  Back to cited text no. 1      
2.Volgas DA, Stannard JP, Alonso JE. Nonunions of the humerus. Clin Orthop Relat Res 2004;419:46-50.  Back to cited text no. 2      
3.Clifford PC. Fractures of the neck of the humerus: A review of the late results. Injury 1980;12:91-5.  Back to cited text no. 3      
4.Court-Brown CM, Garg A, McQueen MM. The translated two-part fracture of the proximal humerus. Epidemiology and outcome in the older patient. J Bone Joint Surg Br 2001;83:799-804.  Back to cited text no. 4      
5.Neer CS II. Nonunion of the surgical neck of the humerus. Orthop Trans 1983;7:389.  Back to cited text no. 5      
6.Scheck M. Surgical treatment of nonunions of the surgical neck of the humerus. Clin Orthop 1982;167:255-9.  Back to cited text no. 6      
7.Wirth MA. Late sequelae of proximal humerus fractures. Instr Course Lect 2003;52:13-6.  Back to cited text no. 7      
8.Antuña SA, Sperling JW, Sánchez-Sotelo J, Cofield RH. Shoulder arthroplasty for proximal humeral nonunions. J Shoulder Elbow Surg 2002;11:114-21.  Back to cited text no. 8      
9.Duralde XA, Flatow EL, Pollock RG, Nicholson GP, Self EB, Bigliani LU. Operative treatment of non-unions of the surgical neck of the humerus. J Shoulder Elbow Surg 1996;5:169-80.  Back to cited text no. 9      
10.Galatz LM, Iannotti JP. Management of surgical neck nonunions. Orthop Clin North Am 2000;31:51-61.  Back to cited text no. 10      
11.Healy WL, Jupiter JB, Kristiansen TK, White RR. Nonunion of the proximal humerus. A review of 25 cases. J Orthop Trauma 1990;4:424-31.  Back to cited text no. 11      
12.Jupiter JB, Mullaji AB. Blade plate fixation of proximal humeral non-unions. Injury 1994;25:301-3.  Back to cited text no. 12      
13.Lin J, Hou SM. Locked-nail treatment of humeral surgical neck nonunions. J Trauma 2003;54:530-5.  Back to cited text no. 13      
14.Nayak NK, Schickendantz MS, Regan WD, Hawkins RJ. Operative treatment of nonunion of surgical neck fractures of the humerus. Clin Orthop Relat Res 1995;313:200-5.  Back to cited text no. 14      
15.Ring D, McKee MD, Perey BH, Jupiter JB. The use of a blade plate and autologous cancellous bone graft in the treatment of ununited fractures of the proximal humerus. J Shoulder Elbow Surg 2001;10:501-7.  Back to cited text no. 15      
16.Rodriguez-Merchan EC, Gomez-Castresana F. Internal fixation of nonunions. Clin Orthop Relat Res 2004;419:13-20.  Back to cited text no. 16      
17.Walch G, Badet R, Nové-Josserand L, Levigne C. Nonunions of the surgical neck of the humerus: Surgical treatment with an intramedullary bone peg, internal fixation, and cancellous bone grafting. J Shoulder Elbow Surg 1996;5:161-8.  Back to cited text no. 17      
18.Adedapo AO, Ikpeme JO. The results of internal fixation of three- and four-part proximal humeral fractures with the polarus nail. Injury 2001;32:115-21.  Back to cited text no. 18      
19.Agel J, Jones CB, Sanzone AG, Camuso M, Henley MB. Treatment of proximal humeral fractures with Polarus nail fixation. J Shoulder Elbow Surg 2004;13:191-5.  Back to cited text no. 19      
20.Kazakos K, Lyras DN, Galanis V, Verettas D, Psillakis I, Chatzipappas Ch, et al. Internal fixation of proximal humerus fractures using the Polarus intramedullary nail. Arch Orthop Trauma Surg 2007;127:503-8.  Back to cited text no. 20      
21.Parsons M, O'Brien JR, Hughes JS. Locked intramedullary nailing for displaced and unstable proximal humerus fractures. Tech Shoulder Elbow Surg 2005;6:75-86.  Back to cited text no. 21      
22.Rajasekhar C, Ray PS, Bhamra MS. Fixation of proximal humeral fractures with the Polarus nail. J Shoulder Elbow Surg 2001;10:7-10.  Back to cited text no. 22      
23.Sosef N, Stobbe I, Hogervorst M, Mommers L, Verbruggen J, van der Elst M, et al. The Polarus intramedullary nail for proximal humeral fractures. Outcome in 28 patients followed for one year. Acta Orthop 2007;78:436-41.  Back to cited text no. 23      
24.Sturzenegger M, Fornaro E, Jakob RP. Results of surgical treatment of multifragmented fractures of the humeral head. Arch Orthop Trauma Surg 1982;100:249-59.  Back to cited text no. 24      
25.Mølster A, Gjerdet NR, Strand RM, Hole RM, Hove LM. Intramedullary nailing in humeral shaft fractures. Mechanical behaviour in vitro after osteosynthesis with three different intramedullary nails. Arch Orthop Trauma Surg 2001;121:554-6.  Back to cited text no. 25      


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1]


This article has been cited by
1 “Internal fixation of proximal humeral fractures using the Polarus intramedullary nail: our institutional experience and review of the literature”
Peter V Giannoudis,Fragiskos N Xypnitos,Rozalia Dimitriou,Nick Manidakis,Roger Hackney
Journal of Orthopaedic Surgery and Research. 2012; 7(1): 39
[Pubmed] | [DOI]
2 Where do locking screws purchase in the humeral head?
Stefano Brianza,Götz Röderer,Damiano Schiuma,Ronald Schwyn,Alexander Scola,Florian Gebhard,Andrea E. Tami
Injury. 2012; 43(6): 850
[Pubmed] | [DOI]



 

Top
Print this article  Email this article